Provider Demographics
NPI:1497387674
Name:MATLOCK, AMANDA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CHANTRY DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-7565
Mailing Address - Country:US
Mailing Address - Phone:217-617-1271
Mailing Address - Fax:
Practice Address - Street 1:5210 N SERVICE RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-3950
Practice Address - Country:US
Practice Address - Phone:636-278-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020004378225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist